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Chapter: Medicine Study Notes : Patient Management

History Taking

Always ask why they‟ve come: and why that is a concern to them (what are they scared of?)

History Taking


·        Always ask why they‟ve come: and why that is a concern to them (what are they scared of?)

·        Key skills:

o   Establishing rapport

o   Asking questions in a logical order

o   Observing non-verbal queues

o   Proper interpretation

·        Record positive & negative findings.  Always amplify positive findings:

o   Time course

o   How quickly did it come on (what were you doing then), pattern since then

o   Site and radiation

o   Character

o   Severity

o   Aggravating or relieving factors

o   Associated symptoms

o   Previous occurrences

·        For each potential cause of a symptom think of:

o   Detail of the symptom

o   Other symptoms you would expect if that cause

o   Ask about risk factors of that cause

Talking with Children


·        Do:

o  Engage them

o  Explain who you are and why you are seeing them

o  Use language and concepts that are age appropriate

o  Reassure if seeing separate from parents

o  Outline confidentiality issues with older children or adolescents

·        Don‟t threaten:

o  The child‟s sense of loyalty to their family

o  Their defences against unbearable emotional pain

·        Interviewing preschoolers (3 – 5 years):

o  Get down to their level, use simple language

o  Take things at their pace

o  Can use play, drawings and stories

o  Ask about everyday world

o  Watch verbal and non-verbal communication

o  See with parent

·        School age children (6 - 11 years):

o  Can be structured

o  Ask about feelings (sadness, anger, etc) as well as daily life

o  Ask about family, school, friends, problems, worries

o  Wishes, hopes for the future

o  Very abstract, open-ended questions can be confusing

  Talking with Adolescents


·        Keys to effective intervention:

o  A positive relationship

o  Thorough assessment

o  Inclusive of family and young person

o  Plans made with the young person and family

·        Building a trusting relationship: introductions

o  Friendly, confident welcome but still professional

o  Introduce yourself directly to the teen, „And is this your mum?‟

o  Clear introductions: yourself, your role, what you‟ll be doing and why

o  Clear boundaries: explain that you see young people alone and with family and why: 

§  „You‟re on your way to being an adult. Want to support that process. But your parents also still have a role‟

§  Allows them both to say things they might not in front of the other

o  Outline confidentiality: 

§  „I want to talk about confidentiality. Do you know what that means?…. Want to keep your information private‟ 

§  „There are 3 things I can‟t keep a secret: if someone‟s harming you, if you‟re harming yourself or if you‟re harming someone else. I need to do something about it – but will tell you what I‟m doing‟ 

§  „Will talk to my colleagues for review – to check I‟m doing the best I can‟

§  Consider what you put in notes (they get around).  Use standardised abbreviations. 

o  If adolescent doesn‟t want you to tell parents (and you think it‟s in adolescents best interests for them to know): 

§  Why doesn‟t teen want parents to know („You seem worried about your parents knowing this. Can you tell me about that?‟)

§  Attempt to persuade the teen to tell her parents

§  Offer to tell them yourself

·        Keys to building the relationship:

o  Be keen to get to know this young person now

o  Accepting atmosphere

o  Respect

o  Non-threatening explanations

o  Give adolescent some control – encourage normal independence

o   Reveal hidden agendas

o   Give them time to talk – hold off asking questions

o   Make plans with the young person and family 

o   If they don‟t want to talk, probably anxious/frightened. “It seems you‟re pretty angry about being here. Did someone make you come?”

·        Communication:

o   Use language that is understood (no medical or adult jargon).  Check understanding

o   Listen

o   Move from less sensitive to more sensitive topics

o   Move from third person approach to the personal


·        Set clear boundaries: It is appropriate to identify what is and is not acceptable behaviour (eg creating risk of harm to themselves or others). Middle adolescents still require the security of clear boundaries. However, try not to be judgemental


·        Beware:

o   Transference: person projects their feelings about someone else (eg parents) onto you 

o   Counter-transference: You transfer feelings appropriate to someone else (eg your own kids) onto the adolescent (eg act as though you were their parent)

o   Objectivity: understand the most likely reason they won‟t talk is that they‟re frightened


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